Provider Demographics
NPI:1255566287
Name:CRANDALL CITY MARKET INC
Entity type:Organization
Organization Name:CRANDALL CITY MARKET INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER & PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KURT
Authorized Official - Middle Name:
Authorized Official - Last Name:JAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:817-429-2571
Mailing Address - Street 1:200 E RENFRO ST
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-3917
Mailing Address - Country:US
Mailing Address - Phone:817-295-1051
Mailing Address - Fax:817-295-2041
Practice Address - Street 1:3563 ALTON RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-2834
Practice Address - Country:US
Practice Address - Phone:817-429-2571
Practice Address - Fax:817-921-6075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-20
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX264183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1255566287Medicaid
4552281OtherNCPDP PROVIDER IDENTIFICATION NUMBER